ACCIDENT INVESTIGATION

CORPORATE SAFETY TRAINING

29 CFR 1904

WELCOME

YOUR INSTRUCTOR

COURSE OBJECTIVES
NOTE
This Course Is Designed to Introduce Basic Skills in Accident Investigation. Root cause analysis and statistical evaluation of accidents can be very complex. This course is designed for the majority of cases that can be diagnosed rapidly and where outside assistance is not normally required.

COURSE OBJECTIVES
(Continued)

Accident Prevention. Introduce Accident Investigation & Establish Its Role in Todays Industry. Introduce Some Basic Skills in the Recognition & Control of Occupational Hazards. Provide Basic Accident Investigation Skills for Supervisors. Introduce Accident Investigation Techniques.

BASIS FOR THIS COURSE

Statistically, accident investigation results in prevention Elimination of workplace injuries & illnesses where possible Reduction of workplace injuries & illnesses where possible Development of efficient accident investigative procedures OSHA Safety Standards require:      Accidents be investigated Training be conducted Hazards and precautions be explained A Safety program be established Job Hazards be assessed and controlled

REGULATORY STANDARD
THE GENERAL DUTY CLAUSE FEDERAL - 29 CFR 1903.1
EMPLOYERS MUST: Furnish a place of employment free of recognized hazards that are causing or are likely to cause death or serious physical harm to employees. Employers must comply with occupational safety and health standards promulgated under the WilliamsSteiger Occupational Safety and Health Act of 1970.
OSHA ACT OF 1970

APPLICABLE REGULATIONS
29CFR - SAFETY AND HEALTH STANDARDS 1904 - RECORDKEEPING REQUIREMENTS

ACC IDENT INVESTIGATION

APPLICABLE REGULATIONS
ANSI - Z16.2 - 1995 INFORMATION MANAGEMENT FOR OCCUPATIONAL SAFETY AND HEALTH ANSI - Z16.3 - 1994 INJURY STATISTICS, EMPLOYEE OFF THE JOB INJURY EXPERIENCE RECORDING AND MEASURING

OSHA CIVIL PENALTIES POLICY

BEFORE MARCH 1, 1991: VIOLATION NARRATIVE: TEN (10) EMPLOYEES WERE NOTED NOT WEARING EYE PROTECTION IN AREAS WHERE A REASONABLE PROBABILITY OF EYE INJURY COULD OCCUR. PENALTY: $500
DANGER

EYE PROTECTION REQUIRED BEYOND THIS POINT

OSHA CIVIL PENALTIES POLICY

(Continued)

AS OF MARCH 1, 1991: CHANGES IN PENALTY COMPUTATION: 1. PENALTIES BROKEN OUT INDIVIDUALLY. 2. PENALTIES INCREASED SEVEN FOLD.

OSHA CIVIL PENALTIES POLICY

(Continued)

AS OF MARCH 1, 1991: VIOLATION NARRATIVE: TEN (10) EMPLOYEES WERE NOTED NOT WEARING EYE PROTECTION IN AREAS WHERE A REASONABLE PROBABILITY OF EYE INJURY COULD OCCUR. $ 10 VIOLATIONS TIMES $500 = $5000 $ 5000 TIMES SEVEN = $35,000 PENALTY: $35000 BEFORE MARCH, 1991: $500 AS OF MARCH, 1991: $35,000

PROGRAM REQUIREMENTS
ALL EMPLOYERS MUST:

Review job specific hazards Implement corrective actions Conduct hazard assessments Conduct accident investigations Provide training to all required employees Install engineering controls where possible Institute administrative controls where possible Control workplace hazards using PPE as a last resort
ACC
IDENT INVESTIGATION

ACCIDENT INVESTIGATION PROGRAM

ACCIDENT INVESTIGATION IS IMPORTANT

A GOOD PROGRAM WILL HELP: Improve quality. SAFETY Improve absenteeism. STATISTICS Maintain a healthier work force. Reduce injury and illness rates. Acceptance of high-turnover jobs. Workers feel good about their work. Reduce workers compensation costs. Elevate SAFETY to a higher level of awareness.

ACCIDENT INVESTIGATION IS ALSO PREVENTION

It is estimated that in the United States, 97% of the money spent for medical care is directed toward treatment of an illness, injury or disability. Only 3% is spent on prevention.

Self-Help Manual For Your Back H. Duane Saunders, MSPT by Educational Opportunities

PROGRAM IMPLEMENTATION
IMPLEMENTATION OF AN ACCIDENT INVESTIGATION PROGRAM REQUIRES: DEDICATION PERSONAL INTEREST MANAGEMENT COMMITMENT
NOTE: UNDERSTANDING AND SUPPORT FROM THE WORK FORCE IS ESSENTIAL, WITHOUT IT THE PROGRAM WILL FAIL!

KEY PROGRAM ELEMENTS

TRAINING SAFETY COMMITTEE WORKSITE ANALYSIS STATISTICAL REVIEWS MEDICAL MANAGEMENT PROMPT INVESTIGATIONS SUPERVISOR INVOLVEMENT HAZARD PREVENTION AND CONTROL

KEY PROGRAM ELEMENTS

(Continued)

WORKSITE ANALYSIS
 RECORDS REVIEW  PERIODIC SURVEYS  JOB HAZARD ANALYSIS  SYSTEMATIC SITE ANALYSIS

SAF ETY

KEY PROGRAM ELEMENTS

(Continued)

SAFETY COMMITTEE
      GOAL SETTING WRITTEN PROGRAM EMPLOYEE INVOLVEMENT REGULAR PROGRAM ACTIVITY TOP MANAGEMENT COMMITMENT PERIODIC PROGRAM REVIEW AND EVALUATION

KEY PROGRAM ELEMENTS

(Continued)

HAZARD PREVENTION AND CONTROL

    PPE REDUCTION ENGINEERING CONTROLS ADMINISTRATIVE CONTROLS OPTIMIZATION OF WORK PRACTICES
DANGER

EYE PROTECTION REQUIRED BEYOND THIS POINT

MANAGEMENTS ROLE
CONSIDERATIONS:
1. SUPPORT THE PROCESS. 2. ENSURE YOUR SUPPORT IS VISIBLE. 3. GET INVOLVED. 4. ATTEND THE SAME TRAINING AS YOUR WORKERS. 5. INSIST ON PERIODIC FOLLOW-UP & PROGRAM REVIEW. 6. IMPLEMENT WAYS TO MEASURE EFFECTIVENESS.

THE SUPERVISORS ROLE

CONSIDERATIONS:
1. TREAT ALL NEAR-MISSES AS AN ACCIDENT. 2. GET INVOLVED IN THE INVESTIGATION. 3. COMPLETE THE PAPERWORK (WORK ORDERS, POLICY CHANGES, ETC.) TO MAKE CORRECTIVE ACTIONS. 4. GET YOUR WORKERS INVOLVED. 5. NEVER RIDICULE ANY INJURY. 6. BE PROFESSIONAL - YOU COULD SAVE A LIFE TODAY. 7. ATTEND THE SAME TRAINING AS YOUR WORKERS. 8. FOLLOW-UP ON THE ACTIONS YOU TOOK.

THE EMPLOYEES ROLE

CONSIDERATIONS:
1. REPORT ALL ACCIDENTS AND NEAR-MISSES IMMEDIATELY. 2. CONTRIBUTE TO MAKE CORRECTIVE ACTIONS. 3. ALWAYS PROVIDE COMPLETE AND ACCURATE INFORMATION. 4. FOLLOW-UP WITH ANY ADDITIONAL INFORMATION.

WRITTEN PROGRAM
WRITTEN PROGRAMS MUST BE:
 DEVELOPED  IMPLEMENTED  CONTROLLED  PERIODICALLY REVIEWED

SAFETY COMMITTEE
COMMITTEES SHOULD:
Hold regular accident review meetings. Document meetings. Encourage employee involvement. Bring employee complaints, suggestions, or concerns to the attention of management. Feedback without fear of reprisal should be provided. Analyze statistical data concerning accidents, and make recommendations for corrective action. Follow-up is critical.

PROGRAM REVIEW AND EVALUATION

EVALUATION TECHNIQUES INCLUDE: Analysis of trends in injury/illness rates. Job hazard analysis assessments. Employee surveys. Review of results of facility evaluations. Up-to-date records of job improvements tried or implemented. Before and after surveys/evaluations of job/worksite changes.

INDUSTRIAL HYGIENE CONTROLS

ENGINEERING CONTROLS
 Work Station Design  Process Modification

FIRST CHOICE
 Tool Selection and Design  Mechanical Assist

ADMINISTRATIVE CONTROLS
 Training Programs  Pacing

SECOND CHOICE

 Job Rotation/Enlargement  Policy and Procedures

PERSONNEL PROTECTIVE EQUIPMENT

 Gloves  Shields  Non-Slip Shoes

LAST CHOICE

 Wraps  Eye Protection  Aprons

ACCIDENT CAUSATION Domino Theory. Multiple Causation Theory.

ACCIDENT CAUSATION
Domino Theory.
The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the injury itself. The accident which caused the injury is in turn invariably caused or permitted directly by the unsafe act of a person and/or a mechanical or physical hazard.

ACCIDENT CAUSATION
Domino Theory. (One act or condition)
The unsafe act: Climbing a defective ladder. The unsafe condition: A defective ladder. The corrective action 1: Replace the ladder. The corrective action 2: Forbid use of ladder.

ACCIDENT CAUSATION
Multiple Causation Theory.
Factors combined in random fashion to cause accidents.

ACCIDENT CAUSATION
Multiple Causation Theory. (Contributing factors)
Was he or she properly trained? Was he or she reminded not to use it? Did the employee know not to use it? Why did the supervisor allow its use? Did the supervisor examine the job first? Why was the defective ladder not found?

ACCIDENT CAUSATION
Unsafe Acts
Horseplay. Defeating safety devices. Failure to secure or warn. Operating without authority. Working on moving equipment. Taking an unsafe position or posture. Operating or working at an unsafe speed. Unsafe loading, placing, mixing, combining. Failure to use personal protective equipment.

ACCIDENT CAUSATION
Unsafe Conditions (Environmental)
Improper PPE. Improper tools. Improper guarding. Poor housekeeping. Improper ventilation. Defective equipment. Improper illumination. Unsafe dress or apparel. Hazardous arrangement.

ACCIDENT CAUSATION
Unsafe Personal Factors
Fatigue. Unclassified Improper attitude. Defective hearing. Defective eyesight. Muscular weakness. Lack of required skill. Intoxication (alcohol, drugs). Lack of required knowledge

ACCIDENT CAUSATION
Behavioristic Causes
Improper attitude. Lack of knowledge or skill. Physical or mental impairment

ACCIDENT CAUSATION
Types of Accidents
Slip, Trip. Struck by. Overexertion. Struck against. Fall on same level. Fall to different level. Caught in, on, or between. Contact with - heat or cold. Contact with - electric current. Inhalation, absorption, ingestion, poisoning.

ACCIDENT CAUSATION
Key Facts
Accident type. Nature of injury. Source of the injury. Location of accident. Hazardous condition. Affected part of body.

ACCIDENT CAUSATION
Assessing the Facts
Nationality. Language. Occupation. Gender. Department. Name of supervisor. Years employed. Length of time on job. Responsibility. Age. Type of accident. Environmental cause. Unsafe act. Behavioristic cause. Cost. Time lost.

ACCIDENT CAUSATION
Steps in Causal Analysis
1. Obtain the supervisor report of the accident. 2. Obtain the injured workers report (if possible). 3. Obtain reports from witnesses, if any. 4. Investigate the accident. 5. Record all the facts. 6. Assess the specifics of the accident. 7. Correlate the specifics with known trends. 8. Determine a course of action to take. 9. Assign responsibility for corrective action. 10. Follow-up as required.

ACCIDENT REPORTING
WHAT SHOULD BE REPORTED: All injuries or job-related illnesses. Near-miss incidents. Vehicular, structural or equipment damage. Procedural deficiencies. Potentially unsafe conditions. Potentially unsafe behaviors.

CONDUCTING THE INVESTIGATION

Purpose of the Investigation:
Determine principal causes. Determine contributing causes. Develop strategies for corrective action. Establish a timetable for corrective action. Assign responsibility for corrective actions.

CONDUCTING THE INVESTIGATION

Continued

Collecting the data:

JHA assessment forms. Direct observation. Video Tape. Action photographs. Documentary accounts. Accident statistics. Employee interviews. Employee surveys.

CONDUCTING THE INVESTIGATION

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TANGIBLE INDICATORS: Accident Records Production Records Personnel Records Employee Surveys
SAFETY STATISTICS

CONDUCTING THE INVESTIGATION

Continued

TEAM COMPOSITION: Supervisor. Safety officer. Maintenance. Field experts (if needed). Care provider (if needed). Injured employee (if possible). Who else can you think of that may be needed?

CONDUCTING THE INVESTIGATION

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PRINCIPAL QUESTIONS TO BE ANSWERED: WHO? WHAT? WHY? WHEN? WHERE? HOW?

CONDUCTING THE INVESTIGATION

Continued

WHO?
Who was injured? Who was working with him/her? Who else witnessed the accident? Who else was involved in the accident? Who is the employee's immediate supervisor? Who rendered first aid or medical treatment?

CONDUCTING THE INVESTIGATION

Continued

WHAT?
What was the injured employees explanation? What were they doing at the time of the accident? What was the position at the time of the accident? What is the exact nature of the injury? What operation was being performed? What materials were being used? What safe-work procedures were provided?

CONDUCTING THE INVESTIGATION

Continued

WHAT?
What personal protective equipment was used? What PPE was required? What elements could have contributed? What guards were available but not used? What environmental conditions contributed? What related safety procedures need revision? What shift was the employee working? What ergonomic factors were involved?

CONDUCTING THE INVESTIGATION

Continued

WHEN?
When did the accident occur? When did the employee start his/her shift? When did the employee begin employment? When was job-specific training received? When did the supervisor last visit the job?

CONDUCTING THE INVESTIGATION

Continued

WHY?
Why did the accident occur? Why did the employee do what he/she did? Why did co-workers do what they did? Why did conditions come together at that moment? Why was the employee in the specific position? Why were the specific tool/equipment selected?

CONDUCTING THE INVESTIGATION

Continued

WHERE?
Where did the accident occur? Where was the employee positioned? Where were eyewitnesses positioned? Where was the supervisor at the time? Where was first aid initially given?

CONDUCTING THE INVESTIGATION

Continued

HOW?
How did the accident occur? How many hours had the employee worked? How did the employee get injured (specifically)? How could the injury have been avoided? How could witnesses have prevented it? How could witnesses have better helped? HOW COULD THE COMPANY HAVE PREVENTED IT?

CONDUCTING THE INVESTIGATION

Continued

WHAT'S NEXT?
Instruct employee in proper behavior? Warn employee of potential hazard? Supply appropriate safeguard? Supply appropriate PPE? Eliminate the unsafe condition? Repair or modify the unsafe condition? Implement procedural changes?

CONDUCTING THE INVESTIGATION

Continued

INTERVIEWING WITNESSES: Select a comfortable, private location. Set the person at ease. Explain that the situation, not them is the focus. Solicit ideas to prevent future recurrence. Consider diagrams or drawings. Remain neutral in your demeanor. Take notes or record the discussion. Review the statements before terminating.

WRITING THE REPORT

REPRESENTING THE DATA: Condense into the company accident form. Compile statistical data for representation. Assign responsibility and prioritize. Make recommendations for correction. Recommend a timetable for correction. Consider funding for corrective actions. Forward copies to OSHA as required. Distribute internally as required. Follow-up at periodic intervals.

WRITING THE REPORT

Continued

FORMULATING CONTROL MEASURES

TRAINING INITIATION OR ENHANCEMENT ELIMINATE OR REDUCE EXPOSURE ENGINEERING CONTROL MEASURES ADMINISTRATIVE CONTROL MEASURES APPLICATION OF SAFE WORK PRACTICES PERSONAL PROTECTIVE EQUIPMENT

FOLLOW-UP
THE GREATEST DEFICIENCY IN ACCIDENT INVESTIGATION IS LACK OF COMPETENT FOLLOW-UP!

INCIDENCE RATES
INCIDENCE RATE CALCULATION: Incidence rates can be
calculated by counting the incidences and reporting the recordable injuries per 100 full time workers per year per facility.

(NUMBER OF NEW CASES X 200,000*) NUMBER OF HOURS WORKED/FACILITY/YEAR

* 200,000 = Approximate annual work hours for 100 workers per facility. * The same method can be applied to departments production lines, or job types with each facility.

JOB DESIGN
GOOD JOB DESIGN
REDUCES
Discomfort, Fatigue, Aches & Pains Injuries & Illnesses, Work Restrictions Absenteeism, Turnover, Complaints, Poor Performance, Poor Vigilance

AVOIDS

ABATES Accidents, Production Problems,

Poor Quality, Scrap/Rework

JOB DESIGN
Continued

GOOD JOB DESIGN

EMPLOYEE: PREVENTS
Economic Loss, Loss in Earning Power, Loss in Quality of Life, Pain & Suffering

EMPLOYER: PREVENTS
Economic Loss, Loss in Expertise, Compensation Costs, Damaged Goods & Equipment

TIPS FOR USING CONTRACTORS

REMEMBER, YOU CONTROL YOUR FACILITY OR AREA! REVIEW THEIR PROCEDURES WITH THEM BEFORE STARTING THE JOB! DETERMINE THEIR SAFETY PERFORMANCE RECORD! DETERMINE WHO IS IN CHARGE OF THEIR PEOPLE! DETERMINE HOW THEY WILL AFFECT YOUR EMPLOYEES!

OSHA'S PERCEPTION OF A SUCCESSFUL PROGRAM

1. DETAILED WRITTEN REPORTS. 2. DETAILED WRITTEN PROCEDURES 3. EXTENSIVE EMPLOYEE TRAINING PROGRAMS 4. PERIODIC REINFORCEMENT OF TRAINING 5. DISCIPLINED PROGRAM IMPLEMENTATION 6. FOLLOW-UP

WORK AT WORKING SAFELY

Training is the key to success in managing safety in the work environment. Attitude is also a key factor in maintaining a safe workplace. Safety is, and always will be a team effort, safety starts with each individual employee and concludes with everyone leaving at the end of the day to rejoin their families. Patricia A. Ice Industrial Hygienist